MERCY GENERAL HOSPITAL
1. Top 10 Disparities
The following table lists the ten largest health equity disparities identified for this reporting period.
Disparities for each hospital equity measure are identified by comparing the rate ratios by stratification groups. Rate ratios are calculated differently for measures with preferred low rates and those with preferred high rates. Rate ratios are calculated after applying the California Health and Human Services Agency's "Data De-Identification Guidelines (DDG)," dated September 23, 2016.
The table below highlights the ten widest health equity disparities identified by hospitals and hospital systems during this reporting period. Measure names have been shortened for display purposes. To view each measure in full, please download the complete Hospital Equity Report using the link below.
| Measure | Stratification | Stratification Group | Stratification Group Rate | Reference Group | Reference Rate | Rate Ratio |
|---|---|---|---|---|---|---|
|
1.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.9% | Hispanic or Latino | 13.3% | 2.60 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 16.6% | Private | 7.2% | 2.30 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.6% | Private | 7.2% | 2.20 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.0% | 18 to 34 | 8.3% | 1.80 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.7% | 18 to 34 | 8.3% | 1.80 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 14.2% | 18 to 34 | 8.3% | 1.70 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.9% | Hispanic or Latino | 13.3% | 1.40 |
|
8.
HCAI 30-Day readmission MHD
|
Sex Assigned at Birth | Male | 17.7% | Female | 16.2% | 1.10 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 14.2% | Hispanic or Latino | 13.3% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 14.6% | Female | 13.8% | 1.10 |
2. Equity Plan
HCAI All-Cause Unplanned 30-day Hospital Readmission Rate for Race and Ethnicity
• Disparity #1: American Indian or Alaska Native patients (Rate 34.0); Disparity #7: Black or African American patients (Rate 18.9); Disparity #9: Asian patients (Rate 14.2)
• Reference Group: Hispanic or Latino (Rate: 13.3)
Measurable Objectives: Reduce the 30-day all-cause unplanned hospital readmission rate among Black/African American, Asian, and American Indian/Alaska Native patients by 2.5% within the next 12 months.
Actions:
• Utilize patient data to identify common medical conditions, social challenges and other factors to develop targeted interventions to address this disparity.
• Provide comprehensive cultural humility training for all staff interacting with patients, designed to enhance awareness of implicit bias and foster skills in culturally sensitive and respectful communication practices that improve patient engagement and satisfaction.
• Conduct patient screening for social determinants of health (SDOH), then employ the Unite Us platform to bridge gaps in care by addressing identified needs and ensuring their successful resolution through a closed-loop referral process.
• Evaluate and revise patient education materials for adherence to California/National Culturally and Linguistically Appropriate Services standards.
• Assess current availability and utilization of professional medical interpreters for all languages spoken by patient population, ensuring 24/7 access.
HCAI All-Cause Unplanned 30-day Hospital Readmission Rate for Payer
• Disparity #2: Medicaid beneficiaries (Rate 16.6); Disparity #3: Medicare beneficiaries (Rate 15.6)
• Reference Group: Private (Rate: 7.2)
Measurable Objectives: Reduce the 30-day all-cause unplanned hospital readmission rate among patients with Medi-Cal and Medicare by 2.5% within the next 12 months.
Actions:
• Leverage patient data to identify common medical conditions, social challenges, payor, and primary care affiliation that correlate with higher readmission rates. This analysis will directly inform the development of targeted interventions to address this disparity.
• Strengthen partnerships with Enhanced Care Management providers, Federally Qualified Health Centers and other primary care practices, and payors to enhance coordinated care and improve transitions to effectively reduce readmission rates across our shared patient population.
• Employ the Unite Us platform to bridge gaps in social determinants of care by addressing identified needs and ensuring their successful resolution through a closed-loop referral process.
• Implement strategies to increase patient knowledge and utilization of Cal-AIM benefits, specifically prioritizing enrollment in Enhanced Care Management and arranging for medically-tailored meal delivery prior to discharge.
HCAI All-Cause Unplanned 30-day Hospital Readmission Rate for Age
• Disparity #4: Age 50 to 64 (Rate 15.0); Disparity #5: Age 65+ (Rate 14.7); Disparity #6: Age 35 to 49 (Rate 14.2)
• Reference Group: Age 18 to 34 (Rate: 8.3)
Measurable Objectives: Reduce the 30-day all-cause unplanned hospital readmission rate among patients aged 35-49 yrs., 50-64 yrs. and 65+ by 2.5% within the next 12 months.
Actions:
• Utilize patient data to assess age-specific risks for readmissions (e.g., cognitive impairment, frailty, social isolation for 65+; chronic disease progression, addiction for 35-64) to develop targeted interventions to address this disparity.
• Integrate mental health screening and referral pathways as behavioral health diagnosis often impacts readmissions.
• Strengthen coordination with skilled nursing facilities and rehabilitation centers for appropriate post-acute care for older adults.
Monitoring and Evaluation Plan:
• Review readmission data within each disparity group to identify trends. Present findings to hospital leadership and relevant committees.
• Adjust action plan based on effectiveness of interventions and emerging data. Share findings with staff and community partners.
3. Structural Measures
| Centers for Medicare & Medicaid Services (CMS) Hospital Commitment to Health Equity Structural (HCHE) Measure | Yes/No |
|---|---|
Our hospital system strategic plan identifies priority populations who currently experience health disparities |
Yes |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
Yes |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
Yes |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
Yes |
Our hospital system inputs demographic and/or social determinant of health information collected from patients into structured, interoperable data elements using a certified EHR technology |
Yes |
Our hospital system stratifies key performance indicators by demographic and/or social determinants of health variables to identify equity gaps and includes this information in hospital performance dashboards |
Yes |
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews key performance indicators stratified by demographic and/or social factors |
Yes |
4. Web Address for Equity Report
5. Download Equity Measures Report
Click on the link below to download the equity measures report.
Click on the link below to download all equity measures reports.